COMPLICATIONS BUNION SURGERY
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COMPLICATIONS BUNION SURGERY
COMPLICATIONS IN HALLUX ABDUCTO VALGUS SURGERYINTRODUCTIONRecurrence of deformity can occur in the face of any procedure performed for the correction COMPLICATIONS BUNION SURGERY of the hallux abducto valgus (HAV) deformity (1-6). In general these procedures are selected based upon their ability to address either structural or dynamic components of the deformity depending upon the presumptive etiology. It is common to perform both an osseous correction (structural re-arrang COMPLICATIONS BUNION SURGERYement) and a soft tissue balancing procedure (dynamic rebalancing) in an attempt to address combination deformities. The recurrence rate after the mosCOMPLICATIONS BUNION SURGERY
t common of HAV procedures, the distal metaphyseal osteotomy, has been reported between 1.85% and 10%. (2, 3, 6). Revision surgery pursued after a comCOMPLICATIONS IN HALLUX ABDUCTO VALGUS SURGERYINTRODUCTIONRecurrence of deformity can occur in the face of any procedure performed for the correction COMPLICATIONS BUNION SURGERYion in the same location may well increase the risk of nerve entrapment, the development of a painful or unsightly scar, vascular compromise, wound and bone healing complications as well as the risk of chronic edema, nerve irritation or entrapment and the development of chronic pain. In addition, as COMPLICATIONS BUNION SURGERY in any surgical procedure, revision surgery necessarily includes the risk of infection, over correction and under correction of the deformity.EVALUATCOMPLICATIONS BUNION SURGERY
ION AND PROCEDURE SELECTIONThe subjective complaintWhile conservative measures should always be exhausted many patients suffering from complications oCOMPLICATIONS IN HALLUX ABDUCTO VALGUS SURGERYINTRODUCTIONRecurrence of deformity can occur in the face of any procedure performed for the correction COMPLICATIONS BUNION SURGERY To ensure that the patient's goals and expectations are understood it is prudent to begin with a cursory exercise where the patient is asked to point to the target of their most important discomfort and to describe their pain in that area thoroughly. Is the target of tenderness at the Is* metatarso COMPLICATIONS BUNION SURGERYphalangeal joint (MTPJ). the hallux interphalangeal joint (HIPJ), beneath the metatarsal head or in a combination of areas? Often, the target of tendeCOMPLICATIONS BUNION SURGERY
rness is actually beneath the second MTPJ due to the inability of the Is' MTPJ to bare weight. Once the location of the chief complaint is determined COMPLICATIONS IN HALLUX ABDUCTO VALGUS SURGERYINTRODUCTIONRecurrence of deformity can occur in the face of any procedure performed for the correction COMPLICATIONS BUNION SURGERYs, burning and pins & needles sensations are often associated with entrapment neuritis or sensory neuropathy indicating that a nerve decompression may be required as a sole procedure or as an adjunctive portion of the surgical plan. When the complaint includes pain about the inferior aspect of the I COMPLICATIONS BUNION SURGERY9' metatarsophalangeal joint (MTPJ) this may indicate an abnormal articulation with a sesamoid bone or fibrous adhesions between the plantar plate andCOMPLICATIONS BUNION SURGERY
the sesamoids and therefore may require a release of the capsular and sesamoidal structures about the periphery of the MTPJ. This can result from an COMPLICATIONS IN HALLUX ABDUCTO VALGUS SURGERYINTRODUCTIONRecurrence of deformity can occur in the face of any procedure performed for the correction COMPLICATIONS BUNION SURGERYhead. Fig. 1 When the patient describesa painful grinding with motion of the joint loose bodies or intra articular damage is likely and suggests degenerative changes of one or both chondral surfaces of the MTPJ. Such crepitation and dysfunction may indicate the need for an arthroplasty if not a join COMPLICATIONS BUNION SURGERYt destructive procedure depending upon the nature and extent of the chondral defects present. Tightness, cramping and / or spasm of the extensor halluCOMPLICATIONS BUNION SURGERY
cis longus (EHL) tendon are often associated with lateral bow stringing of the structure and a hallux over or under ridding the 2rrt digit. These struCOMPLICATIONS IN HALLUX ABDUCTO VALGUS SURGERYINTRODUCTIONRecurrence of deformity can occur in the face of any procedure performed for the correction COMPLICATIONS BUNION SURGERYaluation in Complications of HAV SurgeryEvaluation of recurrent or residual hallux abducto valgus should be performed in a step wise fashion to most consistently identify the full extent of deformity and dysfunction. Clinical evaluation includes both weight bearing and non weight bearing examination COMPLICATIONS BUNION SURGERYs of the foot and ankle, identical to that performed prior to first time elective bunion surgery. The stance evaluation is the key to determine the 1'COMPLICATIONS BUNION SURGERY
- ray position and alignment under normal weight bearing conditions.Weight bearing assessment will reveal the true nature of the deformity be it strucCOMPLICATIONS IN HALLUX ABDUCTO VALGUS SURGERYINTRODUCTIONRecurrence of deformity can occur in the face of any procedure performed for the correction COMPLICATIONS BUNION SURGERY 2a & b So too the presence of compensatory digital deformities, such as flexor or extensor substitution and flexor stabilization can shed light onto additional components of the functional problem. When thoroughly conductedthis portion of the clinical evaluation will demonstrate the true nature of COMPLICATIONS BUNION SURGERYthe deformity and muscle - tendon imbalances which will have a weighty impact on procedure selection. When the weight bearing condition reveals shiftiCOMPLICATIONS BUNION SURGERY
ng of load to the lesser MTPJ’s it becomes obvious that the 1* MTPJ is dysfunctional. Fig. 3 a & b. The gait examination can be done strictly by visuaCOMPLICATIONS IN HALLUX ABDUCTO VALGUS SURGERYINTRODUCTIONRecurrence of deformity can occur in the face of any procedure performed for the correction COMPLICATIONS BUNION SURGERYclinical evaluation without the benefit of additional technical support. When watching the patient it is best to be methodical and review the patient from head to toe as they walk away and walk towards their starting point. Noting posture, position and alignment of the axial and appendicular skeleto COMPLICATIONS BUNION SURGERYn will provide the most comprehensive assessment. This exam should reveal a predictable heel to toe gait pattern with stride length and cadence that fCOMPLICATIONS BUNION SURGERY
alls into normal parameters given the patients habitus. Taking note of shoulder, hip and knee alignment should prompt adjunctive orthopedic consultatiCOMPLICATIONS IN HALLUX ABDUCTO VALGUS SURGERYINTRODUCTIONRecurrence of deformity can occur in the face of any procedure performed for the correction COMPLICATIONS BUNION SURGERYon is interrupted as is the case when an abductory twist is present or if antalgia. vaulting or splinting away from the 1st MTPJ is obviated in gait. A completely apropulsive gait Will be evident when the Is* MTPJ is significantly subluxed. dislocated or impinged. In addition, the weight bearing exa COMPLICATIONS BUNION SURGERYm reveals the extent of r' metatarsal head prominence whether it is dorsal, medial, plantar or a combination and this helps to clarify the structuralCOMPLICATIONS BUNION SURGERY
deformity present such asr- metatarsal elevatus and hallux limitus. sesamoid apparatus dysfunction or end stage 1* MTPJ subluxation.The non weight beaCOMPLICATIONS IN HALLUX ABDUCTO VALGUS SURGERYINTRODUCTIONRecurrence of deformity can occur in the face of any procedure performed for the correction COMPLICATIONS BUNION SURGERYtal planes are considered since the deformity is typically multiplanar. Whether or not the deformity is reducible IS an important clue as to whether the condition is flexible enough to be corrected with revision of the original procedure (assuming a distal metaphyseal osteotomy and soft tissue balan COMPLICATIONS BUNION SURGERYcing) or if an alternate procedure is warranted. The examination of the 1st MTPJ begins with stabilizing the l51 ray at the metatarsal neck and manipuCOMPLICATIONS BUNION SURGERY
lating the hallux at the MTPJ level. With the foot at 90 degrees to the ankle and the STJ in neutral position the hallux is manipulated into a rectus COMPLICATIONS IN HALLUX ABDUCTO VALGUS SURGERYINTRODUCTIONRecurrence of deformity can occur in the face of any procedure performed for the correction COMPLICATIONS BUNION SURGERY to evaluation to eliminate the effects of hyper mobility and masking of structural deformities such as metatarsus primus elevatus. When motion is absent, limited in dorsiflexion, or restricted to solely plantar flexion then it is suspected that there is a metatarsus primus elevatus present and furt COMPLICATIONS BUNION SURGERYher study is required. If the Is* MTPJ motion is limited with a bone-on-bone end range of motion or when crepitation is present a degenerative conditiCOMPLICATIONS BUNION SURGERY
on is suspected and significant articular defects are likely. If there IS limitation with the joint held in a congruous position and a spongy end rangCOMPLICATIONS IN HALLUX ABDUCTO VALGUS SURGERYINTRODUCTIONRecurrence of deformity can occur in the face of any procedure performed for the correction COMPLICATIONS BUNION SURGERYed. If the medial column exhibits hyper mobility and the Is' metatarsocuneiform joint is excessively mobile then the peroneus longus muscle becomes ineffective at both plantar flexing the I8' ray and abducting the fore foot allowing the I81 ray to deviate medially and rotate into varus (4, 5).To det COMPLICATIONS BUNION SURGERYermine the transverse plane deformity again the first metatarsal is stabilized at the metatarsal neck. With the hallux placed into neutral position onCOMPLICATIONS BUNION SURGERY
the metatarsal head the range of motion of the 1st MTPJ is then assessed. If the motion at the I8’ MTPJ remains unrestricted with the joint in a congGọi ngay
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